The Need for Global Health Education in Medical Training

"I have mixed feelings about global health... I mean, we have problems in our own country."

"I'm more interested in health care innovation and entrepreneurship. Not global health."

After hearing countless similar statements from my peers in medical school, I realized that there is a basic discrepancy between what they interpreted as global health and my own understanding of the concept. Common discourse among medical students creates a dichotomy between medicine and global health, between local and global. This dichotomy is not only false but also dangerous.

So what exactly is "global health"? While there is no single, commonly accepted definition, the Committee on the U.S. Commitment to Global Health offers the following: "health problems, issues, and concerns that transcend national boundaries, and may best be addressed by cooperative actions...and the goal of improving health for all people by reducing avoidable disease, disabilities, and deaths." This rather succinct definition has several powerful implications on how we understand "global health" and approach our roles and responsibilities within the field, regardless of our motivations and end goals.

Transcending National Boundaries.
At the most basic level, the definition supplied links global health to globalization. In our increasingly interconnected world, national boundaries carry decreasing significance with regards to disease control. We saw this most recently and dramatically with the Ebola outbreak - an outbreak that we, in the U.S., largely ignored until it reached our soil. With roughly three billion flight passengers per year, it is not surprising that a disease outbreak that emerged across the world could not be nationally or even regionally contained. As technology makes the world smaller, we must ensure that the medical profession is prepared to keep up.

This responsibility is not assigned solely to infectious disease specialists. With basic epidemiology training, we should all, as future physicians, be able to recognize and report suspected disease outbreaks, particularly as diseases, such as West Nile, that we thought were limited to more tropical environments creep northward and show up in our primary care facilities. We, as trusted medical authorities to our patients, should be able to communicate information, to inform our patients of preventive measures and address their anxieties with realistic probabilities of disease spread.

With the movement of people across countries, we will encounter cultures, attitudes, and even disease profiles that are increasingly diverse. Immigrants often carry both infectious and non-infectious diseases that reflect the epidemiology of their country of origin rather than destination. For example, migrants from low and middle-income countries "LMICs" may be at greater risk of liver, esophageal and stomach cancers, which are prevalent in developing countries, than cancers that are more prevalent here. And due to barriers to access both abroad and in the U.S., and our unfamiliarity with global epidemiology, these cancers are often detected late and thus have poorer prognoses. If we aim to be the best physicians we can be, we should be able to recognize and address the unique health care needs of all of our patients, including visitors and immigrants.

As the Ebola outbreak and many outbreaks before it taught us, we do not live in isolation. We cannot continue to ignore the weak healthcare infrastructure that exists abroad. Boozary, Farmer, and Jha (2014) suggest that:

If the Ebola virus surfaced in Boston or Toronto, there is little doubt that their health systems, despite shortcomings, could effectively contain and then eliminate the disease with far lower case-fatality rates than those reported now in West Africa... The answer lies not with the virus, but in the collective failure to ensure the availability of adequate health care staff, resources, and systems required for the delivery of high-quality health care services.

The increasing global burden of chronic diseases presents a unique opportunity to redirect our focus toward health systems strengthening both in LMICs and at home, with the dual purpose of controlling both infectious and non-infectious diseases.

Engaging in Cooperative Action.
Recognizing the growing number of medical students interested in global health, many medical schools are expanding the number of clinical rotations offered abroad. These rotations are certainly valuable to those who have already fostered an interest in global health; but they also have the potential to be unexpectedly valuable to those who are not so inclined.

Clinical work abroad should be approached with humility, a recognition that we have just as much if not more to learn and gain from the communities in which we work as they do from us. Studies suggest that medical students and residents who complete a rotation in resource-limited settings may become more able physicians. Removed from technology-intensive environments, medical students undergoing rotations in resource-limited settings must learn how to think outside the box, minimizing the use of expensive tools unless absolutely necessary. Imagine a world where all physicians were trained as such - we would likely see a reduction in the excessive medical testing that contributes to our rapidly rising health care expenditure.

Indeed, we have many lessons to learn from LMICs when it comes to efficiency in the health sector. A few years ago, I had the privilege of hearing Lord Nigel Crisp speak about this very concept, which he terms "co-development." As he discussed, public and private enterprises in developing countries are innovating to meet their disease burdens within limited budgets. Take India, where GE Healthcare Worldwide developed and launched MAC i, a cheap, transportable, and rechargeable ECG intended for use in rural settings. Many LMICs are also innovating to meet their human resource needs. In Mozambique, for example, highly skilled health workers are chosen for further training as tecnicos de cirurgia who are able to perform relatively routine surgeries. The tecnicos' outcomes have been shown to be equivalent to those of surgeons, and they come at a fraction of the training cost and salary. These are innovations that we can adapt to the U.S. context.

High-income countries are beginning to import cost-cutting ideas from abroad. For example, Ivey International Centre for Health Innovation launched the Reverse Innovation Challenge, and challenged participants to tackle Canada's expensive health system by adapting innovations from LMICs to their own country's context. It is time that we encourage such thought across disciplines, including medicine, in the U.S. as well. Improving Health for All People.
By gaining exposure to global health challenges and solutions, we create opportunities for critical thought and innovation in the delivery of health care, both abroad and at home. Whether we have consciously elected to or not, we, as future health professionals, are all working in the field of global health. What role we wish to take in it -- whether macro or micro, active or passive -- is our choice. Yes, through our intensive training, we will have the ability to contribute to "improving health for all people" -- the natural priority for any medical student with a humanitarian focus. But for those without such a bent: to be an apt clinician; to be a cutting-edge innovator; to be a manager, a CEO, or a policy maker, we would all greatly benefit from understanding and appreciating the complexities of globalization and co-development.